CMM-400: Anesthesia Services for Interventional Pain Procedures Version 1.0 Effective February 14, 2020

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CLINICAL GUIDELINES CMM-400: Anesthesia Services for Interventional Pain Procedures Version 1.0 Effective February 14, 2020

Clinical guidelines for medical necessity review of Comprehensive Musculoskeletal Management Services. © 2019 eviCore healthcare. All rights reserved. Comprehensive Musculoskeletal Management Guidelines V1.0

CMM-400: Anesthesia Services for Interventional Pain Procedures CMM-400.1: Definitions 3 CMM-400.2: General Guidelines 3 CMM-400.3: Indications 4 CMM-400.4: Non-Indications 5 CMM-400.5: Procedure (CPT®) Codes 6 CMM-400.6: References 7

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CMM -400.1: Definitions  Conscious sedation includes:  Minimal sedation (anxiolysis) indicates a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilation and cardiovascular functions are unaffected3.  Moderate sedation/analgesia (conscious sedation) indicates a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained3.  Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation3.  Monitored anesthesia care (MAC) includes the administration of sedatives and/or

analgesics often used for mild to moderate sedation. An essential component of MAC is the periprocedural anesthesia assessment and understanding of the patient’s coexisting medical conditions and management of a patient’s actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. The provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. MAC is administered by a certified registered nurse anesthetist (CRNA) or anesthesiologist. Additionally, a provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a mandatory professional qualification to provide MAC7.  General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired3.

CMM-400.2: General Guidelines  The determination of medical necessity for the performance of monitored anesthesia care (MAC) is always made on a case-by-case basis.  The medical necessity of monitored anesthesia care (MAC) is:  Evaluated prior to each procedure and the determination is made independent of any prior medical necessity determinations for monitored anesthesia care (MAC);

and Services for Interventional Pain Procedures  Only considered once an interventional pain procedure is approved or if the interventional pain procedure does not require prior authorization.  Benefits, coverage policies, and eligibility issues pertaining to each health plan may take precedence over eviCore’s guidelines. Providers are urged to obtain written instructions and requirements directly from each payor. Anesthesia

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CMM -400.3: Indications Monitored anesthesia care (MAC) is considered medically necessary when EITHER of the following are met:  Monitored anesthesia care (MAC) will be used during ANY of the following interventional pain procedures8:  Regional sympathetic blocks  Radiofrequency ablation of the medial branch nerves  Discography  Spinal cord stimulator trial and permanent implantation  Vertebral augmentation  Implantation of intrathecal drug delivery systems  There is a presence of ANY of the following:  Attestation that a behavioral health professional has determined that severe anxiety, psychiatric condition(s), or cognitive impairment(s) would decrease 13 patient safety during the procedure  Hyperkinetic movement disorders including ANY of the following12:  Acquired/traumatic/hypoxic brain injury/stroke  Athetoid cerebral palsy  Basal ganglia disease  Dystonia  Familial paroxysmal choreoathetosis  Hemiballismus  Huntington’s Chorea  Multiple sclerosis  Paroxysmal kinesigenic choreathetosis  Spasticity related involuntary movements  Spinal cord injury  Patients at risk for airway obstruction due to an anatomic variation including ANY of the following11,14:  Dysmorphic facial features  History of stridor  Jaw abnormalities (e.g., micrognathia)  Mallampati score of 4  Neck abnormalities (e.g., mass)  Oral abnormalities (e.g., macroglossia)  Pierre-Robin syndrome  Trisomy 21  Significant medical condition that increases the risk for complications including 10 ANY of the following : Services for Interventional Pain Procedures  Active hepatitis  Cardiac disease including ANY of the following: . Poorly controlled hypertension . Implanted pacemaker/defibrillator Anesthesia

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. Moderate to severe reduction in ejection fraction requiring medical treatment  End stage renal disease requiring dialysis  Morbid obesity (BMI ≥ 40 kg/m2)  Pulmonary disease including poorly controlled COPD requiring oxygen  Sleep apnea requiring BOTH of the following during sleep: . BiPAP support . Supplemental oxygen When the criteria for the performance of monitored anesthetic care (MAC) are met, ALL of the following criteria must also be met6:  A preoperative evaluation has been performed by a member of the anesthesia delivery team which includes airway examination and medical assessment.  Informed consent has been obtained with a discussion of alternative sedation

options.  BOTH of the following are present during the delivery of monitored anesthesia care (MAC):  Continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry  A qualified medical professional to recognize and treat airway complications.  Recovery from monitored anesthesia care (MAC) will be managed by skilled nursing personnel with direct supervision by a certified registered nurse anesthetist or anesthesiologist.

CMM-400.4: Non-Indications  Monitored anesthesia care (MAC) for manipulation of the spine or for closed procedures on the cervical, thoracic, or lumbar spine is considered experimental, investigational, or unproven.

Services for Interventional Pain Procedures Anesthesia

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CMM -400.5: Procedure (CPT®) Codes This guideline relates to the CPT® code set below. Codes are displayed for informational purposes only. Any given code’s inclusion on this list does not necessarily indicate prior authorization is required. Pre- authorization requirements vary by individual payor.

CPT® Code Description/Definition Anesthesia for Diagnostic or Therapeutic Nerve Blocks and Injections (When Block 01991 or Injection is Performed by a Different Physician or Other Qualified Health Care Professional); Other Than the Prone Position Anesthesia for Diagnostic or Therapeutic Nerve Blocks and Injections (When Block 01992 or Injection is Performed by a Different Physician or Other Qualified Health Care Professional); Prone Position Anesthesia for Percutaneous Image Guided Procedures on the 01935 Spine and Spinal Cord; Diagnostic

Anesthesia for Percutaneous Image Guided Procedures on the 01936 Spine and Spinal Cord; Therapeutic CPT® Code Considered Experimental, Investigational, or Unproven Anesthesia for Manipulation of the Spine or for Closed Procedures on the Cervical, 00640 Thoracic or Lumbar Spine This list may not be all inclusive and is not intended to be used for coding/billing purposes. The final determination of reimbursement for services is the decision of the individual payor (health insurance company, etc.) and is based on the member/patient/client/beneficiary’s policy or benefit entitlement structure as well as any third party payor guidelines and/or claims processing rules. Providers are strongly urged to contact each payor for individual requirements if they have not already done so.

Services for Interventional Pain Procedures Anesthesia

Comprehensive Musculoskeletal Management Guidelines V1.0

CMM -400.6: References 1. Abram S, Francis M. Hazards of sedation for interventional pain procedures: the anesthesia patient safety foundation newsletter. 27(2):29-31. 2. American American Society of Anesthesiologists, Anesthesiology 2018; 128:437-79. 3. American Society of Anesthesiologists. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Committee of origin: Quality Management and Departmental Administration. Last amended October 15, 2014. 4. American Society of Anesthesiologists. Position on monitored anesthesia care. Last amended October 16, 2013. 5. American Society of Anesthesiologists. Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. April 2010. 6. American Society of Anesthesiologists. Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. March 2018. 7. American Society of Anesthesiologists. Standards and Guidelines Distinguishing Monitored Anesthesia Care from Moderate Sedation/Analgesia. October 17 2018. 8. American Society of Anesthesiologists. Statement on anesthetic care during interventional pain procedures for adults. Last amended October 26, 2016. 9. American Society of Anesthesiologists. Statement on regional anesthesia. Last amended October 25, 2017. 10. American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. 2013; 118:251-70. 11. Early DS, Lightdale JR, Vargo JJ, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy. 2018;98(2)327-337. doi:10.1016/j.gie.2017.07.018. 12. Ene, H. Hyperkinetic movement disorders(including dystonias, choreas). PM&R Knowledge Now. 9/20/14 13. Spine Intervention Society FactFinders For Patient Safety. Conscious Sedation. February 2018. 14. Vargo JJ, Delegge MH, Feld AD, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. The American Journal of Gastroenterology. 2012. doi:10.1038/ajg.2012.112. Services for Interventional Pain Procedures Anesthesia